PHYSICAL PLANT
Supplemental Incident Investigation
Employee/Supervisor Form
EMPLOYEE NAME: __________________________________
INCIDENT DATE: ___________________________________
To be completed by the employee. Answer Yes or No. Comment as necessary in space provided.
_____ Were you physically or mentally capable to perform your assigned duties? If no,
had you notified your supervisor? _____
_____ Had you been properly briefed by your supervisor on the potential incident
hazards and what safety requirements need to be followed to prevent an incident? Did you
identify and report any additional hazards prior to performing the assigned job? _____
_____ Did you feel the job was properly planned and adequate time available to perform
the assigned job without having to hurry through the work?
_____ Were you provided proper personal protective clothing and equipment to safely
perform the assigned job? If yes, were you wearing it? _____
_____ Did you have the correct tool/equipment to perform the task? If yes, was the
tool/equipment in good operating condition? _____
_____ Had you been previously trained by your supervisor or another employee on how
to perform the assigned task?
_____ Was the assigned task difficult enough to require written operating instructions/
procedures? If yes, were you provided written instructions? _____
_____ Did the assigned task require more than one person to perform the task safely? If
yes, were there adequate personnel assigned to the job? _____
_____ Did you inform your supervisor immediately when the incident occurred?
Attachment F
PP/OP 02.02
01/07/2010
Page 1
_____ Do you have a second job away from Texas Tech? If yes, please explain position
functions.
_____ In your opinion, was there any one thing that definitely caused or contributed to
the incident? If yes or no, please explain your reason why the incident may have happened.
__________________________________________
Employee Signature
________________________
Date
SUPERVISOR’S INDORSEMENT:
_____ Did the employee’s assessment and witness statements (if any) accurately
describe/define the cause for the incident? If no, please provide your comments, causes, and/or
actions that are related or contributed to this incident (use additional paper if needed).
_____ Was the incident reported to the Safety Office as soon as possible?
_____ Was a timely evaluation performed on the injured employee to determine reasonable suspicion
for alcohol/drug testing?
_____ Does the process(s) involved in the assigned job need changing?
_____ Could this incident have been prevented? If no, please explain why not.
_____ Do you plan corrective action to prevent this type of incident from occurring in
the future? If yes, please explain.
__________________________________________
Supervisor Signature
________________________
Date
__________________________________________
Superintendent/Manager Signature (if applicable)
________________________
Date
Attachment F
PP/OP 02.02
01/07/2010
Page 2